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Original Articles: Adult Cardiac

Invited Commentary

^a Division of Cardiac Surgery, Catholic University, Largo A. Gemelli, 8, Rome, 00168 Italy
^b Department of Radiology, University of Rome "Sapienza"-St. Andrea Hospital, Rome, 00168 Italy

(Email: amedeo.anselmi{at}alice.it; carlodececco{at}gmail.com).

In the mid-90s, the potential of cardiac cine-magnetic resonance imaging (MRI) in quantitative and observer-independent assessment of myocardial function were apparent. Initially, assessment of left ventricular function in ischemic heart disease was essentially based on systolic/diastolic wall thickening and contrast enhancement of necrotic myocardium and fibrotic scar. Unfortunately, technical limitations of early scanners (poor sensitivity, competitively inferior diagnostic performance, and long acquisition times) relegated MRI for assessment of ischemic myocardial dysfunction to a research role for several years.

Thanks to technologic improvements, cardiac MRI based on high spatial resolution and tissue characterization now represents the gold standard in the assessment of myocardial function and viability and is superior to single photon emission computed tomography (SPECT) scanning and stress echocardiography. Tissue tagging permits visual analysis of myocardial deformation, but we lack a reliable method to quantify these changes. Modelling/multiparametric strain analysis is expected to overcome the aforementioned limitations and to broaden clinical application. This article [1] represents a landmark advance beyond previous works from this distinguished group that have been important in elucidating the feasibility of the technique.

The importance of this article essentially rests on two points:

• The intent to build a database of reference range values for principal strain angles. This is a crucial step in the development of a new diagnostic tool; nonetheless, it is an ambitious objective that cannot be considered definitely achieved with this article. Much larger series of healthy subjects and probably a multi-institutional collaboration are needed to obtain adequate data for generalized use.

• Proof of a very good diagnostic performance of MRI in quantifying viable myocardium and initial strain anomalies.

Cardiac MRI is a powerful instrument, but cost issues will limit indiscriminate application for all patients with questions regarding myocardial viability. Multiparametric strain analysis is not likely to radically renovate current algorithms for coronary revascularization.

As surgeons, we foresee several purposes beyond the applications for which MRI was initially conceived. Indications for left ventricular reshaping procedures remain under discussion, partly because of our current inability to understand the pathology of left ventricular mechanics in individual patients. Similarly, we cannot predict which patients with functional mitral regurgitation will benefit from a surgically remodelled ventricle. Cardiac MRI with left ventricular finite element strain analysis may eventually guide our decision making for these complex cases. Protean features of remodelled ventricles and the unpredictability of surgical outcomes for heart failure still limit widespread application. Thus, we recognize a tremendous need for reliable tools to stratify candidates and customize operations, and thus overcome the limitations of diagnostic echocardiography. Trials to verify finite element/strain analysis MRI for these scenarios are more than welcome; thus, our collaboration with radiologists should now grow closer and closer.

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1. Cupps BP, Bree DR, Wollmuth JR, et al. Myocardial viability mapping by magnetic resonance-based multiparametric systolic strain analysis Ann Thorac Surg 2008;86:1546-1553.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Anselmi, A. Articles by De Cecco, C. N. Search for Related Content PubMed PubMed Citation Articles by Anselmi, A. Articles by De Cecco, C. N. Related Collections Myocardial infarction Related Article